Downloaded from inpractice.bmj.com on March 1, 2012 - Published by group.bmj.
COMPANION ANIMAL PRACTICE
Veterinary practices should establish a clear policy on chemotherapeutic usage and administration to ensure the safe handling of cytotoxic drugs
Safe use of anticancer chemotherapy in small animal practice
Alison Hayes graduated from Glasgow in 1991 and spent five years in mixed and small animal practice in north-west England. She subsequently undertook a threeyear Blue Cross residency in oncology at the Animal Health Trust in Newmarket, where she is now a clinical oncologist. She holds the RCVS certificate in veterinary radiology and is currently studying for an MSc in clinical oncology at the University of Birmingham medical school.
ONCE very much taboo subjects, cancer and chemotherapy are being demystified. Clients are increasingly well informed about the options available for treating cancer in humans and pets alike. Indeed, cancer is now often considered to be a curable disease in humans and there is growing pressure on veterinary practitioners to ensure the appropriate and safe use of cancer therapies in animals. Many cases of cancer can be cured or very effectively managed without causing unnecessary suffering. Chemotherapy plays a central role in managing some common diseases, and many appropriate chemotherapy protocols are cited in the literature. Often these protocols have been adapted or developed within universities or training/research establishments, where clinicians have wide-ranging expertise in cancer-related issues and the dilemmas associated with clinical and ethical patient management. Chemotherapy drugs (also known as cytotoxic, anticancer and antineoplastic drugs) have a narrow therapeutic index, and should not be administered unless the practitioner is familiar with individual drug toxicities and possible drug interactions. This article addresses the safety aspects of administering cytotoxic drugs within the small animal veterinary practice environment, focusing in particular on safety issues relating to the patient, veterinary professionals and carers.
TO TREAT OR REFER?
In Practice (2005) 27, 118-127
Many of the issues and techniques discussed in this article should be considered with respect to individual practice facilities, expertise, staffing levels and time constraints. What may be safe or appropriate practice for one clinic may be unsuitable for another and the onus is on the individual practice to establish protocols that can be safely applied within its own setting. Poor preparation or ad hoc decisions to treat, driven by client pressure or clinical curiosity, are likely to lead to unacceptable risks to the patient and veterinary personnel who are in direct or indirect contact with the patient and drug preparation area. Establishing a practice policy on chemotherapy usage and administration will lead to appropriate and safe working practices, as decisions about treatment with anticancer drugs often have to be made quickly. Onward referral to one of the numerous centres offering specialist, multidisciplinary cancer patient care should be considered at an early stage. A shared care arrangement can work very well and has advantages for the practice and the patient/owner, enabling wider treatment options to be considered and empowering the owner to make appropriate and timely decisions based on the most up-to-date advice available. As with many chronic medical conditions, owners appreciate consistency of care and the
This is a review article and should not be considered a definitive guide to the Control of Substances Hazardous to Health (COSHH) Regulations relating to cytotoxic drugs. It is intended that practices might use this article to assist in establishing a specific health and safety document on chemotherapy usage and administration in discussion with the practice COSHH adviser.
opportunity to discuss any concerns they may have. Once a diagnosis of cancer has been made, events can often move very rapidly and every detail of the animal’s behaviour and wellbeing comes under scrutiny, with owners needing information, reassurance or action without delay. Managing oncology patients and helping their owners can be rewarding, but is also time consuming and difficult in many busy small animal practices.
RISKS OF EXPOSURE
Cytotoxic drugs are mutagenic (cause permanent, cumulative DNA damage), carcinogenic, teratogenic, and some are direct tissue irritants. Much of the information availIn Practice
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METHODS OF EXPOSURE
Where a practice decides to offer chemotherapy. the risk of exposure by any particular route will vary. at the earliest opportunity. and appropriate. It is well recognised that second malignancies occur in previously treated human cancer patients. as well as handling and storage instructions. Staff should be given this written guidance as part of their induction and ongoing in-house training. despite improvements in hospital procedures over the past 20 years. All incidents of unexpected exposure. s Ingestion. The risks associated with occupational exposure to cytotoxic drugs are small when compared with patients treated therapeutically. both male and female. However. written consent obtained. and removal of sharps containers and waste facilities should be kept and monitored to ensure regular thorough cleaning and to prevent waste from accumulating in the area. gloves should be
Double gloving. Risk assessments should be performed and local rules and standard operating procedures. details of cleaning. all such agents are unlicensed for use in animals. and expectant or breast-feeding mothers. 2012 . This is obviously not the case where occupational exposure is concerned. such as spillage or needle stick injuries. these risks can be minimised by good preparation and techniques. MSDSs are required in order to carry out a risk assessment in a practice setting. As well as patient-based case notes. details about any intravenous site employed and the staff involved. broadly speaking. Although much data is available to support the use of cytotoxic drugs in veterinary medicine. and be encouraged to seek advice and assistance. should be drawn up. s Handling of in-patients after they have received chemotherapy. should be recorded separately and stored with other health and safety documentation held by the practice. can reduce contamination
. s Storage and dispensing. s Skin/mucosal absorption.
PERSONAL PROTECTIVE EQUIPMENT
Suitable personal protective equipment (PPE) should be provided for staff. MSDSs provide information on the physical. This should be used and worn appropriately depending on how the drug is prepared and administered. Disposable gloves should be worn at all times when handling cytotoxic drugs. all of who should not be exposed to any cytotoxic drugs. Written instructions on drug usage should be provided so that these may be passed on to others who may be asked to care for the animal in the absence of the primary carer. Studies conducted on human hospital workers have revealed the presence of drugs and their metabolites in body fluids. occupational exposure may occur in the following ways: s Accidental self-injection.bmj. no amount of PPE is likely to provide total protection and it must not be regarded as a substitute for safe practice. waste and body fluids/faeces from treated patients. Owners should be
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When handling chemotherapy drugs. should be kept for all cytotoxic drugs used by the practice. but these cases are deemed to be high risk. This enables the practice to monitor drug usage and rotate staff where possible. details of commissioning and annual safety checks should be kept. thicker gloves give better protection than thinner ones. similar to those used for radiation protection purposes. and are distinct from the data sheets inserted into product boxes. s Drug administration and patient restraint. Separate consideration should be given to those members of staff. the weight and dose of the drug used. reproductive outcomes and leukaemia. certain procedures need to be documented and records held. Where a safety cabinet is used for drug preparation.
informed about this. where necessary. These should cover: s Drug preparation.Published by group. while other reports have demonstrated an association between drug exposure. but are less well understood. or body fluids/faeces from treated animals. the animal which received therapy. This should note the date(s) on which treatment was administered.bmj. Depending on the task being performed and the type of equipment available in the practice. Where a designated room is available. PPE should be comfortable and should not interfere with ease of movement or patient restraint. both of which could promote accidental contamination.com
able on their use is based on animal experiments and human patients who have been given therapeutic doses. Clearly. cytotoxic waste. and expected to follow the guidelines at all times when handling chemotherapy patients and cytotoxic drugs. however. adverse biological effects of a drug. Material safety data sheets (MSDSs). available from drug manufacturers.Downloaded from inpractice. However.com on March 1. which outweighs any future. with removal of the outer pair of gloves after direct drug handling. patients. The biological effects remain impossible to quantify – even when biological monitoring of staff is undertaken. chemical and toxicological properties of the drugs. Owners should be made fully aware of the possible side effects and the likely timing of these reactions. a separate record of all chemotherapy procedures should be kept. it also serves as a back-up record of what treatment was given to which individual animal should patient records be lost. s Inhalation. While no glove provides complete protection. procedures should be designed to keep occupational exposure to chemotherapy drugs and their metabolites to an absolute minimum. who may be planning a family.
respiratory protective equipment. heavy-duty glove. Picture. N. eye/face protection Gown. gloves. and again after the gloves are removed. which can also be purchased separately. prepared and administered. is a compromise and cannot be recommended.
SUGGESTED PERSONAL PROTECTIVE EQUIPMENT ACCORDING TO PROCEDURE Procedure Spillage. gloves. An additional. Double gloving. eye/face protection. Frequent glove changing and double gloving are recommended. additional heavy-duty gloves Gown. should be used together with standard chemotherapy gloves for dealing with spillages and very soiled kennels.bmj. importantly. Hands should be washed before gloves are worn. reduces contamination during the rest of the procedure. N. overshoes. gloves. together with respiratory protective equipment (RPE). polymer-coated gown with tight fitting cuffs should be worn when working with cytotoxic drugs. its correct fitting is available from the Health & Safety Executive. should be worn by all staff involved with chemotherapy administration. This may be deemed acceptable if only occasional treatments are given. Dispensing/administering tablets
*The preparation of cytotoxic drugs without access to suitable methods of operator protection. addi-
tional eye and. gloves.Downloaded from inpractice. as supplied with commercial spillage kits (see box on the right). Staff should be familiar with the contents of such kits and manufacturers’ instructions for their appropriate use. a long-sleeved.com on March 1.com
A long-sleeved. Paper surgical face masks offer no respiratory protection. Mr G. possibly. Advice on suitable RPE and. Picture. eye/face protection. Gloves developed specifically for cytotoxic preparation in isolators are available. Powderfree gloves should be worn. eye protection and overshoes when dealing with spillages and heavily soiled kennels. Shaw
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. disposable. Picture. face protection. respiratory protective equipment Gown. to remove residues that may promote absorption through the glove. 2012 . as powder can adsorb cytotoxic drugs.bmj. There should be no risk of exposure from inhalation or skin mucosal splash when working within a safety cabinet. Hayes
well fitting and should not limit manual dexterity. but regular preparation of drugs in this way should be avoided
Spillage kits are commercially available and should be kept where chemotherapy drugs are stored. Commercially available spillage kits should be placed where drugs are stored. whereby the outer pair of gloves is removed after direct drug handling. together with gloves and eye protection. Mr G. water-resistant gown. In addition to gloves. heavily soiled kennels Minimum personal protective equipment required Gown. but users may find these limit dexterity for other procedures. prepared and administered. However. Cytotoxic spillage kits contain a filtering facepiece or disposable mask (conforming to FFP3 BS EN 149 1992). RPE should also be worn when a decision is taken to prepare drugs outside a safety cabinet. Hayes
Respiratory protective equipment (RPE) should be worn in addition to a gown. gloves Gloves
Preparation of drugs outside a safety cabinet* Administration of injectable drugs Preparation of drugs inside a safety cabinet Unpacking deliveries. such as those offered by an appropriately installed safety cabinet. but may help
Spillages and heavy kennel soiling should be regarded as serious incidents.Published by group. should be worn if drugs have to be prepared outside this environment. Dr S.
N.com on March 1. Many of the common injectable and oral preparations require refrigeration. Picture.Downloaded from inpractice. Mr G. any previous myocardial compromise should be considered before administering anthracycline). by increasing the inter-
dosing interval. unused cytotoxic products. Transparent.
Gloves should always be worn when dispensing cytotoxic drugs. the risk of exposure is from mucosal absorption due to splash or spillage. Drug residues have been found on the outside of manufacturers’ packaging and on surfaces adjacent to stored. Adequate stock control is therefore required. Spectacle-type eye protection and visors do not give full protection and can easily slip. manufacturers’ childproof bottles should not be replaced by conventional tablet bottles). Goggles offer suitable protection and are also very easy to use. an explicit warning not to crush or split tablets and capsules. Thus. blister-packed tablets. the maximum level of PPE is required. these agents should be kept away from any animal or human food sources. zip-lock type bags are very useful for storing pharmacy items. there is no guarantee that the active component of a drug is equally distributed throughout the drug carrier and inadvertent overdosing may result. these should be kept away from any animal and human foods. which is especially useful when multiple items are being dispensed. For drugs stored in the practice pharmacy. apart from accidental self-injection. Drugs metabolised or excreted by
Many oral and injectable cytotoxic drugs require refrigeration. The use of cytotoxic warning tape provides a clear reminder not to open the bag unless suitably protected. Bottles must be clearly labelled. and the patient’s health status should be taken into account when deciding on treatment. local hospital pharmacies and many oral preparations are available on prescription from highstreet chemists. gloves and eye/face protection. To avoid surplus. and should instruct the carer not to crush or split tablets/capsules. This applies even when the tablets are coated. suitable PPE should be worn when handling the product packaging or the drug itself.Published by group. When dealing with a spillage or a heavily soiled kennel. together with instructions to the owner to wear gloves. which is excreted largely unchanged in urine. Tablets should never be split or crushed and capsules should never be opened and divided. Hydration status and recent general anaesthesia may affect the rate of elimination of drugs such as carboplatin. should appear on the label. some practices may charge the client for the entire amount of the drug ordered if the pack size is large or the drug is expensive. metabolism and excretion (pharmacokinetics) of a drug determines its pharmacological action and toxicity. Picture.bmj. an experienced veterinary oncologist should be contacted for advice. Tablets and capsules should be dispensed without altering the manufacturers’ packaging. Shaw
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. The cytotoxic symbol is clearly recognisable and can be used to alert the owner to the content of the bottle or package. Apart from the unacceptable risks of exposure to the operator. When administering injectable drugs. However.bmj. The biochemical and physiological effects of a drug on the body (pharmacodynamics) can be influenced by intercurrent disease and other medications (eg. Safe dosing schedules can be devised for most drugs. chemotherapy may be an infrequent treatment. and to wear gloves. and drugs should only be dispensed by trained personnel. In addition to the usual labelling requirements. If unsure. sourcing an alternative formulation or reverting to the injectable form of the drug. from the time the drug arrives in the practice.com
to avoid mucosal contamination. unusable stock. a separate locked area should be designated. thereby needing adjustment by bringing potentially contaminated gloves up to the face. where possible (eg. DISPENSING AND STOCK CONTROL
Depending on the workload of a practice. they can be abused with disastrous consequences and storage in a separate. Suitable gloves should be provided for the owner to use. which may lead to expensive or difficult to obtain drugs exceeding their shelf-life. wearing suitable PPE. Childproof dispensing is preferable and large bottles can be used to contain single. 2012 . The drug regimen employed should be specifically indicated for the disease and species in question. particularly in cats. Eye protection must be worn at all times when working outside a safety cabinet. plastic. distribution. Dr S. as the entire periphery is in contact with the face. The absorption. Patients should be seen regularly – for haematological monitoring at the very least – and only sufficient medication should be dispensed to last until the next visit.
DRUG AND PATIENT SELECTION
Drug availability should not be the criterion on which therapy is based. locked refrigerator is recommended. Large quantities of oral medications should never be dispensed to an owner. Tablets and capsules should not be removed from blister packs to be dispensed into a practice container. small units of medication may be sourced from cooperative. with the bag only being opened by trained personnel wearing suitable PPE. Although cytotoxic products are not controlled drugs. so adequate protection should be achieved with gown.
multidose bottles avoids the need for reconstitution. Owners should be encouraged to contain and absorb rather than dilute and distribute any soiling. The workspace used for drug preparation should be free of clutter and able to be easily decontaminated after use. 2012 . All prepared fluid bags and syringes should be clearly labelled.Published by group. should not be used to reduce negative or positive pressure build-up. with removal of the outer pair of gloves immediately after drug preparation. nor should syringes containing air be vented directly into the atmosphere. Disposable absorbent mats should be used on horizontal surfaces and spirit-soaked swabs should be applied to shroud needle insertion points to reduce aerosolisation. It should be possible to isolate the room from other areas of the practice in case spillage
The use of rubber stoppered bottles. Cisplatin and fluorouracil are toxic to cats and are contraindicated in this species. Dr S. which should always be practised. Ideally.bmj. and final cleaning with household bleach is recommended. little more than normal hygiene precautions are required. The interaction between cytotoxic drugs and most homeopathic remedies is not known. draught-free room should be used. pregnant women. and men or women who are planning
The hazard of aerosolisation during drug preparation is well recognised.com
a family. but specific instructions should still be given. As with veterinary personnel. Picture.
Owners should be informed of hygiene requirements in the domestic setting before chemotherapy is administered
the liver (eg. This can be minimised with good techniques. Often. Owners are very often concerned about exposure to their other pets. Small amounts of other waste should be double bagged and placed with domestic refuse. this avoids pressure build-up during the preparation of an injectable drug.com on March 1. to increased toxicity. and may find the thought of putting other animals ‘at risk’ unacceptable. well ventilated. rather than themselves. hence. avoiding excessive positive and negative pressure in bottles and syringes. Where this is not possible. which can cause splashing. Dogs should be encouraged to urinate on grass to avoid owners having to clean or hose down solid surfaces. depending on the individual domestic circumstances. The use of ready-to-administer formulations in rubber stoppered. Animals which are incontinent may be deemed unsuitable for treatment. should not have contact with cytotoxic drugs or waste products. avoids the need for reconstitution
A filtered venting device can be used to draw up agents for administration. Dehydration or reduced blood pressure may lead to increased plasma concentration over time and. drug preparation and administration should take place in a designated room. with a liquid repellent filter.
Owners and carers should be aware of the need to clean up and dispose of contaminated waste from their pet. containing ready-touse formulations. low traffic. cyclophosphamide. Solid waste and small amounts of absorbent material can be flushed down the toilet.bmj. as some owners may be unable to safely achieve this. Shaw
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. Commercial reconstitution and venting devices. a quiet. Families with young children who have regular and close contact with pets require special consideration as constant segregation or insisting on regular hand washing may not be achievable.Downloaded from inpractice. such as a regular hypodermic needle placed into the bottle stopper. Drugs should be drawn up. Double gloving. reduces contamination of ancillary objects. even when using a safety cabinet. Air must never be injected back into a bottle. Nonfiltered air vents. are available and help to equalise pressure during reconstitution and as drugs are being drawn up. vincristine and vinblastine) require dose reductions in patients with hepatic impairment. doxorubicin. Work surfaces and the outside of prepared drug syringes and fluid bags should be cleaned with disposable spirit-soaked wipes. This responsibility should be discussed before any drugs are administered.
(right) A suitable safety cabinet for preparing cytotoxic drugs. Some drugs may be given by oral. it should be noted that preparation of cytotoxic drugs without access to suitable methods of operator protection. Simonson
Group 2 Group 3 Group 4 Group 5
Exfoliant Irritant Inflammatory Neutral
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. in addition. but the standard for microbiological safety cabinets (MSCs). making up drugs without such equipment increases the hazard to the operator. more commonly. even when only small volumes are to be given. either after double HEPA filtration back into the room or by a dedicated extraction system to the outside air.Downloaded from inpractice. provides useful information. Applying make-up and lipsalve. E. Mr G. R. Drugs should be prepared inside a suitable safety cabinet. preplaced. A lock on the door will prevent any untimely interruptions during drug administration. N. There is currently no easily applicable. repeated attempts to place a catheter should be avoided. 2012 . and procedures are designed to reduce the risk and consequences of extravasation (eg. Hayes
Food and drink must not be consumed in the preparation area. This may be deemed acceptable if only occasional treatments are given. peripheral catheters and short duration or bolus infusions are standard practice. rapid access to plastic surgeons is ensured should an extravasation be suspected. Picture. Many drugs in regular use are group 1 vesicants and accidental perivascular injections into the subcutaneous or subdermal compartments (extravasation) may result in severe and extensive tissue necrosis requiring aggressive surgical reconstruction or. Equipment should be commissioned after installation to determine the level of protection likely to be achieved as efficiency can be influenced by room traffic. following perivascular doxorubicin injection in a dog. Picture. Poor
COMMONLY USED CYTOTOXIC DRUGS GROUPED ACCORDING TO THE EFFECT OF EXTRAVASATION Type Group 1 Vesicant Examples Doxorubicin Epirubicin Mustine Vinblastine Vincristine Cisplatin Mitoxantrone Carboplatin Methotrexate Asparaginase Cyclophosphamide Cytarabine Extensive tissue necrosis. There is no place for direct venous access and off-the-needle techniques for any cytotoxic drug. However. In all of these systems. infusions during the night are avoided). Very simply. In human wards. but regular preparation of drugs in this way should be avoided. air is filtered through high efficiency particulate absorption (HEPA) filters before being discharged to the atmosphere. Few practices are currently likely to have access to a safety cabinet.
Intravenous injection is the most likely route of administration in a practice setting. limb amputation. the operator plus the drug (class II) based on airflow. The safety of internally vented equipment is currently uncertain. which simply alter local airflow and are counter-productive. subcutaneous or intramuscular routes. over-the-needle catheter should always be used for intravenous administration. In the veterinary setting. such as those offered
by an appropriately installed MSC. which resulted in limb amputation. is a compromise and cannot be recommended. equipment can offer protection to the operator (class I). of which there are many on the market. drugs are routinely delivered via peripherally or centrally placed central venous catheters. worldwide standard relating to equipment specifically for use with chemotherapeutics.Published by group.com on March 1. with airflow directing droplets towards the operator.com
(left) The workspace for drug preparation should be clutter-free and able to be easily decontaminated. and the route of administration should always be verified. or can be designed as a sealed isolator (class III) to offer both operator and drug protection. The maximum level of PPE is required if drugs are prepared outside an MSC. Readers are encouraged to seek the advice of a reputable company to survey their own particular needs. A secure.bmj. These devices are not the same as fume hoods. Conventional laminar airflow cabinets are similarly unsuitable as the product is protected at the expense of the operator. and the Health & Safety Executive should be contacted for specialist advice prior to installing such systems. BS EN 12469 2000. and smoking are also prohibited
occurs.bmj. A vein should not be used within 24 hours of a previous attempted catheterisation or venepuncture. Peripheral catheters must be accurately and securely placed. Disposable absorbent mats should be used to protect horizontal surfaces.
Dr S.bmj. The manufacturer’s advice on administration and dilution should always be checked and followed. The site of drug administration should be recorded and peripheral sites used in rotation. Frequent drawing back during the injection and continued observation of the injection site is recommended so that the infusion can be terminated if extravasation is suspected. The
methods of dealing with an extravasation are specific to each individual drug.Published by group. 2012 . and the advice of an experienced oncologist should be sought immediately.com on March 1. repeated attempts at placement in the same limb compromise vascular integrity and predispose to perivascular leakage. Picture. Regularly used veins can become difficult to catheterise and should be used in rotation and not for routine phlebotomy. Chemical restraint should be considered for nervous or fractious patients. disposable items. Shaw
Leur lok syringes. over-the-needle catheters. direct into a cytotoxic sharps container. Shaw
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.Downloaded from inpractice. 0·9 per cent saline. (right) The catheter securely inserted
(left and right) Once in place.com
(left) Drugs for intravenous injection should be administered via a securely placed over-the-needle catheter. Depending on the drug chosen. The needle and syringe should be disposed of as a single unit. the catheter should be carefully taped to the limb to avoid unscrewing of the T-port
circulation in the chosen limb results in slow drug egress and increases the likelihood of local leakage. clear bungs and tape are useful. where possible. flexible extension sets. An animal should never be left unattended while an infusion is taking place. Picture. (middle) Accurate catheter placement is important. or when larger or prolonged infusions are being given. Dr S.bmj. An attempt to dilute the extravasated drug by injecting saline under the skin should not automatically be performed. water for injection or 5 per cent glucose solution can be used
Used needles should not be recapped. T-ports. saline minibags.
before the catheter and infusion set are removed as a single unit. consequently. Small volume injectables.Published by group.bmj. Good restraint of the animal is essential
The catheter is flushed with normal saline before cytotoxic drugs are injected. the use of the same gauge needle for saline flushes and drug administration enables any pres-
sure changes to be noted more easily. However. Catheters should be flushed with non-heparinised saline immediately prior to drug administration to ensure patency and to remove any traces of heparin. the catheter can then be removed. All needles should be disposed of directly into a suitable sharps container without recapping or removal of the needle from the syringe. and steps should be taken to minimise this exposure. 2012 . vomit.
CONSIDERATIONS FOLLOWING DRUG ADMINISTRATION
Patients excrete potentially harmful drugs and their metabolites in urine.bmj. an extension set or into a freerunning drip line.Downloaded from inpractice. no contact with the drug should occur prior to and during the infusion. a further 10 to 30 ml of saline can be added to the minibag to remove the final. and drugs can often be prepared into 50 ml minibags away from the patient and any associated distractions. can be given via a short extension set. The advantage of administering drugs into extension sets and drip lines is that patients are likely to be easier to restrain and. Injections should never be made when there is resistance. irrespective of whether they have been used to inject drugs or simply for saline flushing. which can cause precipitation of certain drugs. catheters are less likely to be pulled out. such as a T-port (Venisystems.com on March 1. to minimise operator exposure. residual drug volume. a saline flush is repeated to remove traces of drugs that may cause tissue irritation and operator exposure. The giving set should then be flushed via its side port and. Needleless administration is preferred. If the giving set is attached and charged before the drug is added to the bag. Such excretions can potentially contribute to the exposure of veterinary personnel and carers. Bags should be lowered to a comfortable operator height and the injection performed with a spirit-soaked swab to shroud the injection point and help absorb any leakage. Some of these drugs will precipitate in heparin
Spirit-soaked swabs are used to absorb traces of cytotoxic drugs during administration
Catheter removal immediately after drug administration avoids inadvertent exposure of other staff members to cytotoxic agents
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. saliva and sweat for variable periods of time following the administration of injectable or oral preparations. Abbott Ireland). Much of the information discussed below
All personnel should wear protective clothing during drug administration. After administration. at the catheter. Syringes used for drugs and saline flushes should be of a leur lok design and should never be filled to the maximum volume. again. The greatest risk of accidental selfinjection is when recapping a needle. such as vincristine. faeces.com
for small volume infusions. to reduce the risk of accidental self-injection. constant examination of the injection site is still recommended and patients should not be left unattended while an infusion is taking place. Once the infusion is complete.
Cytotoxic bins for DOOP (destruction of old pharmaceuticals) waste are available for drug disposal. Repeating the washing cycle with an empty machine reduces contamination of the next load.helapet.. However. P. STANLEY. OLSEN. Hayes
Acknowledgement The author would like to thank Audrey Scott for her general advice and encouragement during the preparation of this article. British Journal of Industrial Medicine 49. Gloves should be worn when taking blood samples from patients that have recently received cytotoxic drugs. All cytotoxic waste should be treated as special waste and sent for incineration. New England Journal of Medicine 313. Further reading ALLWOOD. excessive storage times must be avoided. when cleaning up soiling. www. Gloves should be worn when cleaning up faeces. W. & WRIGHT. HORNUNG.. individual items may be placed into sealed bags to reduce leaching. Feed bowls and bedding should be washed separately. HSE information sheet MISC615. All patients should be clearly identified as receiving or having recently received chemotherapy. Practices should consult their waste disposal provider for more specific details. Sharps are disposed of in the usual way into cytotoxic sharps disposal units to avoid waste build-up. www. Catheters should be removed immediately after drug administration unless they are clearly marked as contaminated.Published by group. GUSTAVSSON. MAARUP.. Identifying the patient with a colour-coded collar and marking the kennel are easy ways of communicating this to all relevant personnel. However. K. Faeces should be double bagged and placed into clinical waste for incineration. as staff absent during chemotherapy administration may provide ongoing care
Cytotoxic DOOP bins are available.
All members of staff should be aware of in-patients receiving chemotherapy.. VOLLMER. N..Downloaded from inpractice. 4th edn.com
SUGGESTED PRECAUTIONARY PERIODS FOR HANDLING URINE/FAECES FOLLOWING CESSATION OF TREATMENT WITH COMMONLY USED CYTOTOXIC DRUGS* Drug Doxorubicin Vinca alkaloids Cyclophosphamide Cisplatin Route Intravenous Intravenous Any Intravenous Urine 6 days 4 days 3 days 7 days Faeces 7 days 7 days 5 days ?
*Based on human studies
applies equally to veterinary staff and animal carers outside the practice setting. H. Cat litter trays should be cleaned regularly. www. STROM. which may be cared for by staff not present at the time of drug administration.uk s FILTER DEVICES AND MEDICAL CLEANROOM DISPOSABLES. When cancer is diagnosed in veterinary practice..bmj. 1173-1178 SKOV. LINDBOHM. A. B. M. G. & FRIBERG. E. Bagging individual bottles will reduce leaching. Journal of Occupational and Environmental Medicine 41. L. Abingdon. S..hse. As in the domestic setting.co. euthanasia is no longer an automatic decision. Ratcliffe Medical Press NYGREN. As even small DOOP bins can take a long time to fill. 855-861 VALANIS.
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. W.uk s SAFETY CABINETS. T. Dogs should be encouraged to urinate frequently on grass after receiving cytotoxic drugs and patients should be treated and discharged as soon as possible into the care of the owner to avoid inappropriate elimination in the kennel environment.bmj. (Eds) (2002) The Cytotoxics Handbook. RORTH. M.
Veterinary practitioners are treating an ever-ageing population of domestic pets that enjoy a central role in family life. P. and constant and close attention to the issues discussed in this article. This is especially important for in-patients. (2002) Cisplatin contamination observed on the outside of drug vials. (1992) Leukaemia and reproductive outcome among nurses handling antineoplastic drugs. & STEELE. M. 2012 . & HEMMINKI. WINTHEREIK. SAFE HANDLING OF CYTOTOXIC DRUGS. O. the aim should be to contain and absorb rather than dilute and distribute. 555-557 SELEVAN.uk
All soft disposables should be double bagged before disposal. Areas should then be disinfected with household bleach. (1999) Occupational exposure to antineoplastic agents: self-reported miscarriages and stillbirths among nurses and pharmacists.com on March 1. Annals of Occupational Hygiene 46.. R. B.. appropriate PPE should be worn and splashing avoided. L. safe use of anticancer chemotherapy demands best practice. J. B. Where concrete runs must be hosed.gov. Picture. 632-638
Further information s HEALTH & SAFETY EXECUTIVE. A. Mr G. & LYNGE. M.. Prolonged storage should be avoided.kojair. (1985) A study of occupational exposure to antineoplastic drugs and fetal loss in nurses.co.
com on March 1. 2012 .27.bmj.bmj.bmj.bmj.
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Safe use of anticancer chemotherapy in small animal practice
Alison Hayes In Practice 2005 27: 118-127
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